Optimizing Diet to Slow CKD Progression When, Why and How Ouppatham Supasyndh, M.D. Division of Nephrology, Phramongkuklao Hospital
Aims of nutrition care üCorrect sign and symptoms of uremia üPrevent protein-energy wasting (PEW), good nutrition status üSlow disease progression/ delay kidney replacement therapy üPrevent metabolic complications üPrevent cardiovascular complications üPrevent fluid overload üMeal satisfaction
Proteins High biological value protein (HBV) • Essential amino acids • Including animal protein, egg, tofu Low biological value protein (LBV) • Plant-based diet • Including legumes, vegetables, cereals and tubers
Actual BW or Ideal BW? • In a 1959, the Metropolitan Life Insurance Company suggested ‘ideal’ BW for men and women based on weight, height and body frame. • It is used to determine the proper dosage of prescribed medications for patients, • It does not represent the universal criterion for measuring the percentage of body fat and muscle mass since it varies among individuals.
Metropolitan Life Insurance
Thai Anthropometry อปุ ถมั ภ ศุภสนิ ธุ สภาวจิ ัยแหง ชาติ 2556
IBW: Hamwi method Male = 48 kg for the first 152.4 cm + 1.1 kg for each additional cm. Female = 45 kg for the first 152.4 cm + 0.9 kg for each additional cm. No scientific data supported
What is a LPD • Defined as < 0.8 g protein/Kg.BW/day….U.S.RDA • Minimum daily requirement of HBV protein in 95% of US population = 0.46 g/Kg.BW.day • Add 30% of both HBV and LBV protein • Add 30% for safety • Average 0.77 g protein/Kg.BW/day or approximated to 0.8 g protein/Kg.BW/day The Biology of Human Starvation 1944-1945
LPD • KDOQI 2020 guidelines recommend adequate daily energy intake (DEI) of 25-35 kcal/Kg.BW for low protein intake • Calculation of DEI and DPI • If BMI is normal or overweight; using actual BW • If obese or underweight; using normative BW table (ideal BW may not be enough) KDOQI Guideline 2020
Type and Dosages of LPDs Type Protein Intake Description (g/Kg BW/day) Conventional Mixed protein Vegan 0.55-0.6 Vegetable protein Vegan supplemented 0.6-0.8 Vegetable protein, supplemented with 0.6-0.7 EAA and keto-acids VLPD supplemented vegan Vegetable protein only, supplemented 0.28-0.43 with or without protein free food Tailaored solution Vegetable or mixed protein 0.6-0.8
Conventional LPD • Contains 0.6 g/kg BW./day of proteins, of which at least 50% HBV • Provide carbohydrates (55–60% of the total energy intake), and lipids (30–35% of the total energy intake) • Also usually low in phosphate (600–800 mg/day), sodium (2–3 g/day) • Protein-free products include pasta, noodles, bread, biscuits, flour, and precooked soups and desserts • In Italy, where these foods are reimbursed by the national health service Cupisti, A. BMC Nephrol. 2016, 17, 124.
Vegan LPD • Provides 0.6 to 0.7 g/kg BW./day. • The crucial point is to cover the needs for essential AA in the presence of a protein intake lower than the RDA. • The diet is based upon combinations of “cereals” and “legumes” to complement the essential AA since cereals are rich in methionine whereas lysine is well represented in legumes D’Alessandro, C.BMC Nephrol. 2016, 17, 102.
Supplemented Plant-Based Diet • Provide 0.6 g/kg BW./day of unselected mainly plant- derived proteins, supplemented with essential amino acids and/or ketoacids (1 tablet every 8–10 kg of body weight • Including only plant-derived foods (fruits, vegetables, sugars, starches such as pasta and bread, couscous, polenta, and legumes) supplemented with amino acids and ketoacids Piccoli, G.B. Nephrol. Dial. Transplant. 2013, 28, 2295–2305.
VLPD • Contains about 0.3 g/kg/day of proteins, supplemented with a mixture of essential amino acids and ketoacids (1 tablet for every 5 kg of body weight). • This dietary regimen is usually achieved with a vegan diet. KDOQI Guideline 2020. Am J Kid Dis 2020. 76(3) Suppl 1
Indications of LPDs • Prevention and treatment of metabolic and electrolyte disorders • Prevention of PEW • Delay the progression of CKD • Delay the start of RRT • Management of proteinuria and hypertension
Mechanism of Action of LPDs High Protein Diet Low Protein Diet
Proteolytic • Increased TMO fermentation • Salt load • High urea Animal-based diet • High cholesterol High-protein diet • Oxidative stress • Increased metabolic acidosis
Saccharolytic • Favorable gut microbiota fermentation • Decreased BP Plant-based diet • Decreased uremic toxins Low-protein diet • Decreased lipid profile • Decreased inflammation • Slow progression of disease • Decreased metabolic acidosis
TMAO Choline metabolite to trimethylamine N-oxide (TMAO) are associated with • diabetes • renal insufficiency and • vascular diseases
Trimethylamine-N-Oxide (TMAO) Tang, WH. N Eng J Med 2013. 368:17 Wang Z. et al.. Nature 2011. 472;57-63.
Mechanism of TMAO facilitate cholesterol influx into macrophage TMAO Liu TZ, et al. Chin Med J. 2015;128(20):2805-2811.
Tang, WH. N Eng J Med 2013. 368:17
TMAO from ingested L-Carnitine and gut flora between vegan and meat eater Vegan Koeth RA et al. Nat Med 2013 19(5) 576-585. Meat eater
Urinary excretion Obeid R et al. Am J Clin Nutr 2016; 103:576-585.
TMAO vs CKD Stubbs JR et al, J Am Soc Nephrol 27: 305–313, 2016
The Scientific Advisory Committee 2016 Recommend: Average cooked red meat consumption 70 g /day 5 table spoonfuls/ day Wyness L, Proceedings of the Nutrition Society 2016,75:227-232
Effects on renal hemodynamics • Mediated by :- Reduced tubulo-glomerular feedback mechanism Nitric oxide Sallstrom J. Am J Physio Regul Integr Comp Physiol 2010; 299: 1263-1268
Effects on renal hemodynamics Adenosine Macula Densa Afferent vasoconstriction Na+ Decrease GFR Sallstrom J. Am J Physio Regul Integr Comp Physiol 2010; 299: 1263-1268
Effects on renal hemodynamics Macula Densa Increase GFR Na+ AA- Sallstrom J. Am J Physio Regul Integr Comp Physiol 2010; 299: 1263-1268
Effects on renal hemodynamics Sallstrom J. Am J Physio Regul Integr Comp Physiol 2010; 299: 1263-1268
Meta-analyses: Cochrane 2009 0.6 vs high 0.3-0.6 vs high P=O.0009 Fouque et al, Cochrane Database Syst Rev, Issue 3, 2009
Reduction of proteinuria Abbate M. J Am Soc Nephrol 17:2974-2984
Reduction of proteinuria Macrophages TGF-β Abbate M. J Am Soc Nephrol 17:2974-2984
Reduction of proteinuria Complement Pathway Abbate M. J Am Soc Nephrol 17:2974-2984
Reduction of proteinuria Inflammation Collagen Fibroblasts Abbate M. J Am Soc Nephrol 17:2974-2984
Median time Median time 45 M 23 M Chauveau et al. JREN 2007
Contraindications to LPDs Absolute • PEW • Hypercatabolic state (metabolic acidosis) • Anorexia, eating disorders • End of life care management
Contraindications to LPDs Relative • Poor attitude • Psychological • Social barriers (economic, cultural, lackmof support) • Poorly controlled DM • Chronic steroid treatment • GI diseases • Short life-expectency
Side Effects • Weight loss due to reduced energy intake • Muscle mass loss • Depression, psychological discomfort
Dietary Supplements • Calcium (except with KAA) • Vitamins • Iron • KAA
Special Conditions • Diabetes • Obesity • Aging patient • Pregnancy • Short life-expectancy
Diabetes
Diabetes • Add
Obesity • Energy restriction increases protein requirements, so that a low protein diet may not be able to maintain an adequate nitrogen balance, thus increasing the risk of PEW. • When a low-protein diet is indicated in an overweight or obese patient, protein restriction should probably be prescribed with an energy intake covering at least the daily requirements per ideal body weight Bellizzi V. J Nephrol. 2017 Apr;30(2):159-170.
Very Old Age > 80 Years • Protein anabolism is reduced in older individuals and geriatric societies usually advice increasing protein intake of 1.0 to 1.2 g/kg BW./day in elderly individuals, thus particular attention should be placed in protein restriction in elderly CKD patients. Deutz NE, the ESPEN Expert Group. Clin Nutr. 2014 Dec;33(6):929-36.
Very Old Age > 80 Years A supplemented VLPD was able to delay by about one year the need of dialysis in elderly patients with no consequence on morbidity and mortality Brunoli G. Am. J. Kidney Dis. 2007, 49, 569–580.
Pregnancy Moderately protein restricted, plant-based diets, may allow stabilization of kidney function in pregnancy Attini, R. BMC Nephrol. 2016, 17, 132
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